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You find yourself working in a small - I’m talking very small - rural hospital in South America for your summer “break”. The only imaging modalities available are plain X-ray and a small portable ultrasound machine your group-of-four brought along for the trip. There is no MRI, no CT, and no formal ultrasonography. It might not help much if there were any of these however, as the are no radiologists, or any other specialists for that matter, in the hospital. It’s just you and your three friends: a general surgeon, an OB/GYN, and an orthopedist. The two local doctors who are general practitioners have taken the week off. There is, however, a much larger hospital in the nearest city, but it is over a day’s journey away.

Your current patient is a 55-year-old obese diabetic male who presents with right flank pain that has been getting worse for about 7 days. He was started on Bactrim 3 days ago for a urinary tract infection, but continues to worsen. He denies diarrhea, hematuria or dysuria, but has had fever and has been vomiting about once per day. His medications include glipizide, Tylenol, and Bactrim.
altOn exam he is calm, nontoxic, and pleasant, but looks to be in mild distress. His vital signs aren’t bad. Temperature is 97.4, blood pressure 98/58, pulse 108, and respiratory rate is 16 wit a pulse-ox of 98% on room air. Eyes are anicteric. Oropharynx is moist. Lungs are clear. Abdomen is soft and non-tender, but the back has right-sided CVA tenderness. The remainder of the exam is normal.

Laboratory data showed a nondiagnostic urinalysis, possibly because he was already taking antibiotics. The metabolic panel was notable only for a glucose of 216, a sodium of 122, and a creatinine of 1.6. The CBC had a white count that was elevated at 21.4. An ultrasound of the kidneys was normal, but the following image of the liver was also taken. What structures are shown in this image? What abnormal finding is shown?
 

What do you see in the image?

 

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